COMPLICATIONS - CARDIOVASCULAR

G.G. Fernandez-ranvier¹, J. Sicalo², A. Kore², P. Baron^1
1Surgery And Transplantation Institute, Loma Linda University, Loma Linda/UNITED STATES OF AMERICA, ²Surgery And Transplantation Institute, Loma Linda University, Loma Linda/CA/UNITED STATES OF AMERICA

Body: Introduction:
Currently combined kidney and pancreas transplant (KPTx) is the standard of surgical treatment for patients with renal failure due to type 1 diabetes mellitus. The purpose of this study is to reportthe complication of lower gastrointestinal bleeding due to an arterio-enteric fistula (AEF) in patients with KPTx.

Methods:
In this study we report three cases that underwent KPTx and presented with severe gastrointestinal (GI) bleeding secondary to an AEF. Case #1 is a 41 years old (y.o.) male who presented with brightred blood per rectum 35 months after transplant. Case #2 is a 43 y.o. male who presented with melena and severe anemia 1 month after transplant. Case #3 is a 55 y.o. male who presented with syncopeand bright red blood per rectum 2 months after transplant.

Results:
Different diagnostic methods were used in the work-up for the gastrointestinal (GI) bleed depending on the clinical presentation and hemodynamic status of the patient. The work-up for case #1included upper and lower GI endoscopies as well as emergent angiography. He developed an AEF at the right common iliac artery anastomosis (RCIAA). Despite aggressive resuscitation efforts the patientdeveloped hypovolemic shock, multiorgan failure and died soon after. Case #2 underwent upper and lower endoscopies, an angiogram, a tagged red blood cell scan and exploratory laparotomy withintraoperative enteroscopy. Intraoperatively no active bleeding was found. The patient continued to have bleeding and required multiple transfusions. Eventually, the amount of bleeding decreased, andhe was discharged with stable hemoglobin 12 days after admission and continues asymptomatic 14 months later. In case #3 lower GI endoscopy was done but he became hypotensive and was taken to theoperating room. An exploratory laparotomy revealed an AEF at the RCIAA. Bleeding was successfully controlled but he required a femoral-femoral bypass to revascularize his right lower extremity.Patient is doing well 6 months later.

Conclusion:
Lower gastrointestinal bleeding secondary to AEF following KPTx is a rare but severe complication, and carries a significant morbidity and mortality. It is important to be aware that a lower GI bleedin a KPTx patient, especially in the setting of pancreas allograft rejection and severe inflammation may represent a life-threatening massive bleed. Early detection may lead to early angiographic orsurgical intervention leading to lower morbidity and mortality.

Disclosure: All authors have declared no conflicts of interest.